Minimally Invasive Ventral Hernia Repair with Endoscopic Separation of Components

Chapter 28 Minimally Invasive Ventral Hernia Repair with Endoscopic Separation of Components

Michael J. Rosen

The videos associated with this chapter are listed in the Video Contents and can be found on the accompanying DVDs and on Expertconsult.com.

A ventral incisional hernia is a protrusion of viscera through a previous abdominal incision into the subcutaneous tissue; the hernia contents typically are enveloped in a serous sac in continuity with the peritoneum. Because 11% to 20% of laparotomies result in an incisional hernia, incisional herniorrhaphy is one of the most common general surgical procedures, with more than 250,000 cases annually in the United States. Although the full economic burden of abdominal wall reconstruction is unknown, informal industry estimates have suggested that related health care costs amount to $2.5 to $3 billion per year.

An understanding of the objectives of ventral hernia repair can provide insight into the ideal technique and strategy for this procedure. A defect in the ventral abdominal wall predisposes patients to incarceration of the bowel and mesentery, which can lead to obstruction, strangulation, and perforation. In addition to these life-threatening complications, a ventral hernia can cause paradoxical movement of the abdominal contents during respiration, which can compromise pulmonary function (a particular problem in the patient with underlying lung disease). Complaints of back and abdominal pain due to the absence of the abdominal wall musculature also are common with ventral hernia. All of these scenarios can have a negative effect on quality of life, decrease functional activity, and produce long-term disability. Given the wide spectrum of patients suffering from abdominal wall defects and the range of defect anatomy, a tailored approach for each hernia would be prudent.

One of the foremost goals of ventral hernia repair is the prevention of intestinal herniation. Although primary suture repair of the defect could accomplish this goal, this technique was associated with an unacceptably high recurrence rate in all but the smallest of hernias. The introduction of prosthetic mesh dramatically reduced the recurrence rate after incisional hernia repair. Prosthetic mesh can be placed using a variety of techniques; no single technique has been able to provide an acceptable solution in every patient.

Laparoscopic ventral hernia repair was first reported in 1993 and generally was accepted as an approach to ventral hernia repair. In a typical laparoscopic incisional hernia repair, a large prosthetic mesh is placed in the retromuscular and intraperitoneal position. A possible advantage of the laparoscopic approach has been the avoidance of extensive soft tissue dissection; overall, the rate of wound complications and mesh infections has been less with laparoscopic compared with open repair. Although placement of a large, retromuscular mesh to bridge a wide defect can prevent bowel herniation, use of this technique will not produce a functional, dynamic abdominal wall. In the active and thin patient, some form of a bulge or paradoxical motion can persist after repair and may result in patient dissatisfaction. In our practice, we have reserved the typical laparoscopic incisional hernia repair (with a large retromuscular and intraperitoneal mesh) for the obese or elderly patient. A slight bulge often is imperceptible by such a patient and thus of little consequence; furthermore, the risk for wound complications in this scenario usually outweighs other issues.

In 1990, Ramirez and others described a method of hernia repair in which the lateral abdominal wall musculature was separated to provide a tension-free fascial advancement for the repair; this technique was termed components separation. This repair method has undergone several modifications but essentially involves entrance into the lateral abdominal muscular compartment. This typically has been accomplished with large lipocutaneous flaps, incision of the external oblique fascia lateral to the linea semilunaris, and separation of the external and internal oblique muscles. As such, this technique essentially has been a major abdominal wall reconstruction. Problematic wound morbidity has been associated with components separation and has limited its widespread acceptance. Recent modifications, however, have enabled this procedure to be performed with endoscopic access to the lateral abdominal wall while achieving similar myofascial advancement.

Several investigators have begun evaluating the combination of (1) an endoscopic components separation with (2) a laparoscopic repair using a retromuscular and intraperitoneal mesh. Using the laparoscopic technique, the defect can be closed and prosthetic mesh placed to reinforce the repair. This minimally invasive functional abdominal wall reconstruction might offer the ideal physiologic reconstruction of the abdominal wall. This chapter focuses on the technical details of an endoscopic components separation with midline fascial reapproximation and reinforcement with a large subfascial mesh.

Operative indications

An ideal abdominal wall reconstruction for a midline incisional hernia would provide a minimally invasive technique to release the external oblique muscles, enable laparoscopic adhesiolysis, reapproximate the midline, and reinforce the repair with permanent prosthetic material. Ideally, such a reconstruction would be performed without creation of the large lipocutaneous tissue flaps. Our approach is to perform an endoscopic components separation combined with a laparoscopic mesh herniorrhaphy that includes restoration of the linea alba, as described later.

Patient factors that favor a laparoscopic ventral hernia repair include a smaller defect region, lack of severe adhesions, a history of previous prosthetic infection, and a high risk for wound morbidity (e.g., secondary to obesity, advanced age, immunosuppression, or diabetes). Factors that support an open approach include known severe adhesions, a defect that extends to the bony confines of the abdomen (e.g., iliac crest, costal margin), and the need for formal abdominal wall reconstruction. The latter need is common in patients who do manual labor or are young, thin, active, and athletic, particularly if the defect is more than 10 cm wide.

Obese patients should be counseled to lose weight before ventral hernia repair. The morbidly obese patient may be given the option to lose weight by dieting or to undergo a bariatric procedure before definitive repair of the abdominal wall. Cessation of smoking is mandatory for all patients because smoking has been associated with an increased risk for wound complications and repair failure. A patient with a large pannus, skin ulcerations, or an extensive scar may be better served with a panniculectomy or scar revision as part of an open procedure.

The ideal candidate for minimally invasive ventral hernia repair with endoscopic components separation and midline reapproximation is a thin, active patient with an 8- to 10-cm wide defect, without an extensive midline scar, who desires a functional abdominal wall. An active patient who has undergone a previous laparoscopic incisional hernia repair may develop bulge at the repair site that represents flexing of the prosthesis where it bridges the defect. If the patient is dissatisfied with this result, then components separation may be an option for revision. If the patient has a hernial defect 12 cm or more in transverse dimension or has an abdominal wall that has been scarred with multiple stomas, drains, or infections, then midline approximation of the linea alba may not be possible, and other repair options should be considered.

Preoperative evaluation, testing, and preparation

Determination of the width and rostral and caudal extent of the hernia defect is important, as is determining other associated defects, such as “Swiss-cheese” defects (multiple small defects along a midline incision, associated with the sawing action of suture loops) or lateral defects associated with prior stomas. A preoperative abdominal pelvic computed tomography (CT) scan is routine for this determination. In addition, it is important to determine by CT whether there is loss of various layers of the abdominal wall. If a stoma is present, then its exact location within the rectus or the lateral abdominal wall can be ascertained. We no longer perform preoperative bowel preparation because it can produce bowel distention, making adhesiolysis more difficult.

The patient should be counseled before the procedure that transfascial fixation sutures will be placed to secure the mesh and medialize the rectus muscle, so there may be a degree of postoperative discomfort. Placement of an epidural catheter for postoperative pain management can be considered. Hospital stay for several days typically will be required. Managing a patient’s expectations for an immediate flat abdomen is important; although the hernia sac is not excised, it usually becomes obliterated after the defect has been closed. A postoperative seroma still is possible.

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Tags: Video Atlas of Advanced Minimally Invasive Surgery Expert Consult

Jul 20, 2016 | Posted by admin in GASTOINESTINAL SURGERY | Comments Off

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